Claims Operations Manager

OUR COMMITMENT TO A HUMAN HIRING PROCESS

We believe every candidate deserves thoughtful wedo not use AI or automated systems toreview applications. Every application is reviewed bya realhumanmember of our team. Because we take the time to give each submission the attention it deserves our review process may take a little longer and we genuinely appreciate your patience as we work through applications carefully and respectfully.

SERVICE AREA PREFERENCE

While we encourage all interested applicants to apply we do give priority to those who live in or near our service counties: Santa Cruz Monterey Merced San Benito and Mariposa. Our mission ofaccessible quality health care guided by local innovationleadseverything we do and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.

We have an opportunity to join the Alliance as the Claims Operations Manager leading the Claims Operations Unit within the Claims Department.

This position can be located in one of our service counties (Mariposa Merced Monterey Santa Cruz or San Benito) or remotely in California with expected travel to Alliance service area(s) once a quarter. Must reside in California upon hire.

WHAT YOULL BE RESPONSIBLE FOR

Reporting to the Claims Director this position:

• Manages and leads the Claims Operations Unit acts as a subject matter expert and provides guidance on claims operations functions and departmental operations
• Provides management oversight related to planning leading and implementing claims operations activities including audits root-cause analysis quality reporting compliance coordination and governance of claims policies and procedures
• Oversees the full Provider Dispute Resolution (PDR) lifecycle to ensure accurate timely and compliant dispute resolution
• Manages supervises mentors and trains assigned staff

ABOUT THE TEAM

We support the health of our provider relationships. Our teams work closely together to support Alliance members access to care by ensuring medical services are paid to network providers accurately and on time.

THE IDEAL CANDIDATE

• Strong understanding of end-to-end claims and PDR operations (volume accuracy turnaround)
• Uses data and tools to spot trends make decisions and actively identify opportunities for automation
• Solid experience with Medi-Cal and Medicare with compliance built into how they work
• Focuses on fixing root causes instead of quick fixes
• Builds engages and supports teams through coaching accountability and clear expectations
• Brings new ideas challenges the way things are done and works closely with other teams to drive better outcomes

WHAT YOULL NEED TO BE SUCCESSFUL

To read the full position description and list of requirements click here.

• Knowledge of:
• Claims processing functions including data entry adjudication and PDR workflows
• MediCal Medicare and related regulatory requirements that impact claims processing and dispute resolution
• Operational improvement activities workflow design and inventory management within a managed care environment
• Medical terminology billing practices and coding standards relevant to claims adjudication
• Audit processes quality standards and compliance requirements related to claims operations and dispute workflows
• Research analysis and reporting methods
• Ability to:
  • Train mentor supervise and evaluate the work of staff promote an atmosphere of teamwork and cooperation and motivate staff to achieve goals and objectives
  • Develop work plans and workflows and organize and prioritize unit activities to meet performance metrics
  • Organize and prioritize the work of others delegate effectively and follow up on work assignments
  • Interpret apply and explain complex principles policies regulations terms and procedures related to area of assignment
  • interpret operational data identify trends and apply insights collaborate with Claims Quality on PDR analytics and identify opportunities for increased autoadjudication
• Education and Experience:
  • Bachelors degree in Business Healthcare Administration Public Health or a related field
  • A minimum of six years of experience in a healthcare or managed care environment which included a minimum of three years of supervisory or management experience in Medi-Cal and Medicare claims operations (a Masters degree may substitute for two years of the general healthcare or managed care experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

COMPENSATION INFORMATION

• Zone 1 Pay Range: $118000 - $148000
  Typical areas in Zone 1: Santa Cruz San Benito and Monterey Counties Bay Area Sacramento Los Angeles and San Diego areas
  
  
• Zone 2 Pay Range: $110000 - $140000
  Typical areas in Zone 2: Mariposa and Merced Counties Fresno area Bakersfield Eastern California San Luis Obispo area and the Central Valley (except Sacramento)

The applicable salary ranges are based on work location and are aligned to a zone according to the cost of labor in your area. All ranges are subject to change in the future. We are happy to provide the full compensation range for the role answer any questions that you have or share the applicable pay zone for your location if its not one of the typical areas listed. You can reach out to and a member from our Talent Acquisition team will be in touch.

The hiring ranges represent a goodfaith estimate of what we expect to pay for this role upon hire and are not the full compensation ranges. Employees typically have opportunities for growth within the full compensation range over time based on performance and merit. Final compensation will be determined by our compensation philosophy analysis of the selected candidates qualifications (direct or transferable experience related to the position education or training) as well as other factors (internal equity market factors and geographic location).

OUR BENEFITS

Available for all regular Alliance employees working more than 30 hours per benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.

• Medical Dental and Vision Plans
• Ample Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• Robust Health and Wellness Program
• Onsite EV Charging Stations

ABOUT US

We are a group of over 500 dedicated employees committed to our mission of providing accessible quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

Join us at Central California Alliance for Health (the Alliance) where you will be part of a culture that is respectful diverse professional and fun and where you are empowered to do your best work. As a regional non-profit health plan we serve members in Mariposa Merced Monterey San Benito and Santa Cruz counties. To learn more about us take a look at ourFact Sheet.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race color religion sex (including pregnancy) sexual orientation gender perception or identity national origin age marital status protected veteran status or disability status. We are an E-Verify participating employer

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time ongoing basis without current or future needs for any type of employer supported or provided sponsorship.